Cover -- Endorsements -- Title Page -- Copyright Page -- Dedication -- Acknowledgments -- About the Author -- Contributing Authors -- Table of Contents -- Preface: A Note From the Chief Financial Officer -- Foreword -- Introduction -- Part 1: The Road to Inspire -- Chapter 1: Healthcare Reform in the U.S. -- Chapter 2: Answering the Call for Change -- Chapter 3: Laying the Groundwork for a Transitional Care Nurse Program -- Chapter 4: Piloting the Transitional Care Nurse Program -- Chapter 5: Challenges and Roadblocks

Chapter 6: Evaluating and Addressing Highest-Priority Care Transition Needs -- Chapter 7: Getting the Chief Financial Officer to Buy In -- Chapter 8: Creating Successful Partnerships -- Chapter 9: Compliance and Regulatory Concerns Associated With Transitional Care Nursing Programs -- Chapter 10: Documentation and Data Management -- Chapter 11: Spreading the TCN Program and Inspire Model Across the Profession -- Part 2: Inspire Across the Care Continuum -- Chapter 12: Inspire: Mental Health and Substance Abuse -- Chapter 13: Inspire: Pulmonary Rehabilitation for Patients With COPD

Chapter 14: Inspire: Decreasing Hospital Readmissions From Skilled Nursing Facilities -- Chapter 15: Inspire: The Clinical Pharmacist and Medication Management -- Chapter 16: Inspire: Pediatric Community Care -- Chapter 17: Inspire: Management of the Diabetic Patient -- Chapter 18: Inspire: Physical Therapy Evaluation in the Emergency Department -- Chapter 19: Inspire: Palliative Care Program -- Chapter 20: Community Projects -- Appendix A: Mapping Out Workflows With Community Partners: Strategy to Build Teamwork, Trust, and Accountability With Blueprint for Health

Appendix B: Transitional Care Nursing -- Appendix C: Role Clarification for: Hospital-Based Case Manager, Blueprint for Health Medical Home Nurse Case Manager, Transitional Care Nurse -- Appendix D: Transitional Care Nurse Orientation -- Appendix E: Transitional Care Launch -- Appendix F: Examples of Patient Education Tools Created by Interdisciplinary Team Focused on Care Coordination for COPD -- Appendix G: Structure to Maximize Efficiency for ID Rounds Held Daily at 9 a.m. to Review All Inpatients in Med Surg, ICU -- Appendix H: Brochures for Transitional Care Program

Appendix I: Transitions of Care Annual Reports -- Appendix J: Community Care Team Annual Reports -- Appendix K: Community Care Team -- Appendix L: Pediatric Community Care Team Annual Report -- Appendix M: Pulmonary Rehabilitation Reports -- Appendix N: Diabetes Education Annual Reports -- Appendix O: Medication Therapy Management Annual Report -- Appendix P: Youth Screening, Brief Intervention, Referral to Treatment (YSBIRT) Age 12-24 Years -- Appendix Q: Pediatric Community Care Team -- Appendix R: Transitions of Care Program Consent Forms

Includes bibliographical references and index.

"About this book: In today's environment where healthcare costs are outpacing the economy, healthcare systems are shifting from fee-for-service to value-based payment to deliver high-quality care while reducing costs. This shift presents nurses with the opportunity to take the lead in transforming care delivery and achieve the Triple Aim goals: improving patient experience of care, improving health of populations, and reducing per capita healthcare costs."--publisher.

Online resource; title from PDF title page (EBSCO, viewed March 03, 2020).